DPP4 INHIBITORS. Details. Step Therapy Criteria Health Alliance Plan 2019 Date Effective: 04/01/2019
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1 DPP4 INHIBITORS Janumet 50 mg-1,000 mg tablet Januvia 50 mg tablet Janumet 50 mg-500 mg tablet Onglyza 2.5 mg tablet Januvia 100 mg tablet Onglyza 5 mg tablet Januvia 25 mg tablet Tradjenta 5 mg tablet For new starts only, claims will process for Januvia, Janumet, Onglyza, or Tradjenta if a claim for metformin has been processed in the past 120 days. 1
2 FLUVASTATIN fluvastatin 20 mg capsule fluvastatin ER 80 mg tablet,extended fluvastatin 40 mg capsule release 24 hr For new starts only, claims for fluvastatin will process if a claim for simvastatin, atorvastatin, or rosuvastatin is processed in the past 120 days. 2
3 GLP-1 AGONISTS Bydureon 2 mg/0.65 ml subcutaneous Trulicity 0.75 mg/0.5 ml subcutaneous pen injector pen injector Bydureon BCise 2 mg/0.85 ml Trulicity 1.5 mg/0.5 ml subcutaneous pen subcutaneous auto-injector injector Byetta 10 mcg/dose(250 mcg/ml)2.4 ml Victoza 3-Pak 0.6 mg/0.1 ml (18 mg/3 subcutaneous pen injector ml) subcutaneous pen injector Byetta 5 mcg/dose (250 mcg/ml)1.2 ml subcutaneous pen injector For new starts only, claims will process for Victoza, Trulicity, Bydureon, or Byetta if a claim for metformin has been processed in the past 120 days. 3
4 MYRBETRIQ Myrbetriq 25 mg tablet,extended release Myrbetriq 50 mg tablet,extended release For new starts only, claims will process for Myrbetriq if a claim for oxybutynin, tolterodine, or trospium has been processed in the past 120 days. 4
5 RASAGILINE rasagiline 0.5 mg tablet rasagiline 1 mg tablet For new starts only, claims will process for rasagiline if a claim for selegeline has been processed in the past 120 days. 5
6 SGLT2 INHIBITORS Invokana 100 mg tablet Synjardy XR 10 mg-1,000 mg tablet, Invokana 300 mg tablet extended release Jardiance 10 mg tablet Synjardy XR 12.5 mg-1,000 mg tablet, Jardiance 25 mg tablet extended release Synjardy 12.5 mg-1,000 mg tablet Synjardy XR 25 mg-1,000 mg tablet, Synjardy 12.5 mg-500 mg tablet extended release Synjardy 5 mg-1,000 mg tablet Synjardy XR 5 mg-1,000 mg tablet, Synjardy 5 mg-500 mg tablet extended release For new starts only, claims will process for Invokana, Jardiance, or Synjardy, if a claim for metformin has processed in the past 120 days. 6
7 TYMLOS Tymlos 80 mcg/dose (3,120 mcg/1.56 ml) subcutaneous pen injector FOR NEW STARTS ONLY, CLAIMS FOR FORTEO WILL PROCESS IF A CLAIM FOR ALENDRONATE, RISEDRONATE, OR IBANDRONATE ARE PROCESSED IN THE PAST 120 DAYS. 7
8 ULORIC Uloric 40 mg tablet Uloric 80 mg tablet FOR NEW STARTS ONLY, CLAIMS FOR ULORIC WILL PROCESS IF A CLAIM FOR ALLOPURINOL 300 MG PER DAY IS PROCESSED IN THE PAST 120 DAYS. 8
9 Index B Bydureon 2 mg/0.65 ml subcutaneous pen injector... 3 Bydureon BCise 2 mg/0.85 ml subcutaneous auto-injector... 3 Byetta 10 mcg/dose(250 mcg/ml)2.4 ml subcutaneous pen injector... 3 Byetta 5 mcg/dose (250 mcg/ml)1.2 ml subcutaneous pen injector... 3 F fluvastatin 20 mg capsule... 2 fluvastatin 40 mg capsule... 2 fluvastatin ER 80 mg tablet,extended release 24 hr... 2 I Invokana 100 mg tablet... 6 Invokana 300 mg tablet... 6 J Janumet 50 mg-1,000 mg tablet... 1 Janumet 50 mg-500 mg tablet... 1 Januvia 100 mg tablet... 1 Januvia 25 mg tablet... 1 Januvia 50 mg tablet... 1 Jardiance 10 mg tablet... 6 Jardiance 25 mg tablet... 6 M Myrbetriq 25 mg tablet,extended release... 4 Myrbetriq 50 mg tablet,extended release... 4 O Onglyza 2.5 mg tablet... 1 Onglyza 5 mg tablet... 1 R rasagiline 0.5 mg tablet... 5 rasagiline 1 mg tablet... 5 S Synjardy 12.5 mg-1,000 mg tablet... 6 Synjardy 12.5 mg-500 mg tablet... 6 Synjardy 5 mg-1,000 mg tablet... 6 Synjardy 5 mg-500 mg tablet... 6 Synjardy XR 10 mg-1,000 mg tablet, extended release... 6 Synjardy XR 12.5 mg-1,000 mg tablet, extended release... 6 Synjardy XR 25 mg-1,000 mg tablet, extended release... 6 Synjardy XR 5 mg-1,000 mg tablet, extended release... 6 T Tradjenta 5 mg tablet... 1 Trulicity 0.75 mg/0.5 ml subcutaneous pen injector... 3 Trulicity 1.5 mg/0.5 ml subcutaneous pen injector... 3 Tymlos 80 mcg/dose (3,120 mcg/1.56 ml) subcutaneous pen injector... 7 U Uloric 40 mg tablet... 8 Uloric 80 mg tablet... 8 V Victoza 3-Pak 0.6 mg/0.1 ml (18 mg/3 ml) subcutaneous pen injector
DPP4 INHIBITORS. Products Affected Step 2: Janumet 50 mg-1,000 mg tablet Janumet 50 mg-500 mg tablet Januvia 100 mg tablet Januvia 25 mg tablet
DPP4 INHIBITORS Janumet 50 mg-1,000 mg tablet Janumet 50 mg-500 mg tablet Januvia 100 mg tablet Januvia 25 mg tablet Januvia 50 mg tablet Onglyza 2.5 mg tablet Onglyza 5 mg tablet Tradjenta 5 mg tablet
JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET BYDUREON BCISE 2 MG/0.
ANTI DIABETICS BYDUREON 2 MG SUBCUTANEOUS JANUVIA 25 MG TABLET EXTENDED RELEASE SUSPENSION JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET
Mercy Care Plan. Acyclovir Ointment. Products Affected. acyclovir ointment 5 % external Details. Criteria. Requires use of oral Acyclovir
Acyclovir Ointment Mercy Care Plan acyclovir ointment 5 % external Requires use of oral Acyclovir 1 Adcirca ADCIRCA TABLET 20 MG ORAL Requires use of Sildenafil 2 Albenza ALBENZA TABLET 200 MG ORAL Requires
CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.
ADHD STIMULANTS ATOMOXETINE HCL, DEXEDRINE 10 MG TABLET, DEXEDRINE 5 MG TABLET, DEXMETHYLPHENIDATE HCL, DEXMETHYLPHENIDATE HCL ER, DEXTROAMPHETAMINE 10 MG TAB, DEXTROAMPHETAMINE 5 MG TAB, DEXTROAMPHETAMINE
BYSTOLIC. Products Affected Step 2: BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET. Details BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET
BYSTOLIC BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET authorization for a Step 2 drug may be given. Step 1 Drug(s): generic beta-blockers and/or combinations,
ALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Farm Bureau Health Plans Date Effective: November 1, 2018.
ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID 18351, Version 15 1 ANTIDEPRESSANTS - SCORE Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of the following
5-ASA. Products Affected DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED RELEASE. Details
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5-ASA. Products Affected. Details. Dipentum 250 mg capsule. Lialda 1.2 gram tablet,delayed release
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ALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Optima Tier Gold Formulary Date Effective: November 1, 2018.
ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID 18354, Version 15 1 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of
ADHD STIMULANTS - SCORE
Step Therapy Trillium 5 Tier Effective Date: 12/01/2017 Approval Date: 10/24/2017 ADHD STIMULANTS - SCORE Strattera Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant
ADHD STIMULANTS - SCORE
ADHD STIMULANTS - SCORE Step Therapy Strattera Patient needs to have a paid claim for two generic formulary ADHD stimulant medications. Formulary ID# 00017034 Last Updated: 08/01/2017 1 ALPHA GLUCOSIDASE
Y0133_StepTherapyCriteria _C 10/18/18 Y0133_StepTherapyCriteria _C es 10/18/18
Step Therapy Grid Certain cost-effective drugs must be used before other more expensive drugs are covered. For example, certain brand-name medications will only be covered if a generic alternative has
ALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Health Choice Generations 1 Tier Gold Effective Date: 11/01/2018.
ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 1 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam
ALBUTEROL - SCORE{XE "ALBUTEROL - SCORE"}
Step Therapy ALBUTEROL - SCORE{XE "ALBUTEROL - SCORE"} Ventolin Hfa{XE "Ventolin Hfa"} Trial of ProAir Formulary ID# 00018097 Last Updated: 04/01/2018 1 ANTIDEPRESSANTS - SCORE{XE "ANTIDEPRESSANTS - SCORE"}
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Contents ALPHA BLOCKERS... 3 COLCRYS-PST... 4 DPP-4 INHIBITORS-PST... 5 HIGH RISK MEDICATIONS - SEDATIVE HYPNOTICS... 6
CHRISTUS Health Plan Generations (HMO) 2017 Step Therapy Criteria H1189_PC57 Accepted 11/17/2016 1 Contents ALPHA BLOCKERS... 3 COLCRYS-PST... 4 DPP-4 INHIBITORS-PST... 5 HIGH RISK MEDICATIONS - SEDATIVE
ALPHA BLOCKERS. Products Affected Step 1: Details. Step 2: Rapaflo 4 mg capsule Rapaflo 8 mg capsule
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Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
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DIABETES (1 of 5) Generic. Generic $0 $5 $5-10 $0 $0 $0. Generic $0 $5 $5-10. Generic. Generic $0 $5 $5-10 $0 $0 $0. Generic $0 $5 $5-10 $0 $0 $0
Metformin DIABETES (1 of 5) Glucophage Glucophage XR ER $7 (500mg) $7 (500mg) $5 $5 500mg, 750mg only 500mg, 750mg only Sulfonylurea/Combinations Amaryl Glucotrol glimepiride glipizide $5 $5 Glucotrol
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